Healthcare decision-making is one of the most challenging aspects of medicine. In the past, doctors often based their decisions on dogma or personal experience often influenced by their personal value judgments. With the advent of evidence-based medicine over the past 2 decades, there has been increasing emphasis on basing healthcare decisions upon scientific literature. Evidence-based medicine is an approach intended to optimize medical decision-making by incorporating scientific research. Although this has improved the quality of healthcare decision-making and delivery across the world, is this enough? While evidence-based medicine helps the doctor make decisions for the typical patient, it rarely helps in making decisions for a specific patient. In fact, healthcare decision-making should be based on 4 important considerations: 1) Clinical state and circumstances; 2) Clinical expertise and resources; 3) Research evidence; and 4) Patient values and preferences (Fig. 1).

Fig. 1. Four essential considerations for healthcare decision-making

There is variability in how much freedom in decision-making patients wish to have. Some prefer the ‘Old School’ approach where they look to the doctor to make all healthcare decisions for them. However, it is becoming increasingly popular to use the ‘shared decision-making’ approach in which the doctor and the patient work together to assess the benefits and risks of all treatment options. Our article highlights the need to carefully and systematically consider patient values and preferences in decision-making. Unfortunately, there is lack of training and decision-making aids available to the doctor in achieving this.

Dealing with uncertainties in medicine is a common reality. We not only have to consider the probability of a desired outcome with each treatment strategy but also the value each individual patient places on these outcomes. We describe the 3 most common techniques of valuing outcomes: 1) Rating scale – Using a rating scale, patients can be asked to mark their own health state on this scale. This is a simple method but is the least scientifically robust; 2) Standard gamble – Presenting the patient with a choice between two health states: a health state that is certain and a gamble with a better health state. The goal is to identify a probability of the better health state that would make the patient indifferent to their current state of health and a gamble for the better health state. Although this is the most scientifically robust method, it also measures the patient’s attitude towards risk-taking in addition to valuing the health state; and 3) Time trade-off – This requires assessing the amount of life years a patient is willing to trade to avoid their particular health state. This is scientifically robust and does not capture risk-taking attitudes as the health outcomes are certain.

A thoughtful effort is required to study the information needs of our patients focusing on outcomes that are important to them. Creating scientifically-valid aids would be useful to facilitate patient-physician discussions related to personalized healthcare decision-making, staying away from the one-decision-fits-all cookie cutter approach to practicing medicine.

Aria Fallah

Department of Neurosurgery, David Geffen School of Medicine at UCLA,
Los Angeles, CA, USA

Publication

Moving beyond evidence-based medicine: Incorporating patient values and preferences.
Fallah A
Epilepsy Behav. 2015 Dec

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